Quality improvement fund - justice involved - healthcare for the homeless - houston (HHH) is the city's only standalone, homeless-specific federally qualified health center (FQHC)

Operating three clinics and on-site care teams at seven permanent supportive housing sites, HHH serves 6,500 individuals annually. This population includes those living unsheltered, in emergency shelters, transitional housing, and permanent supportive housing. HHH's care model addresses the unique and complex health and social needs of people without stable housing. Individuals released from correctional facilities face numerous challenges, including chronic illnesses, mental health disorders, and substance use issues. Without adequate support, these conditions often go untreated, worsening health problems and increasing recidivism. According to the national institute of justice, about 40% of incarcerated individuals have chronic conditions like hypertension, diabetes, or asthma. The bureau of justice statistics reveals that nearly two-thirds have mental health issues, such as depression and schizophrenia, and 65% meet criteria for substance use disorders, putting them at high risk for overdose post-release. HHH aims to address these challenges and improve care transitions for this vulnerable population through a specialized, integrated healthcare setting offering comprehensive, person-centered care. Services are CO-located and include medical, dental, mental and behavioral health, specialty care, and wraparound social services. The primary healthcare setting offers a uniquely holistic approach to immediate health concerns and long-term wellness, resulting in greater coordination and continuity of care. Integrated social services assist with housing, employment, and legal aid, while mental health professionals provide counseling, psychiatric care, and substance use treatment. By addressing these interconnected needs, HHH seeks to reduce health disparities, improve outcomes, and enhance stability for justice-involved individuals. For more than ten years, HHH partnered with harris county jail and the local mental health authority to pilot an innovative jail in-reach program aimed at improving post-incarceration care transitions. Through intensive medical case management and RE-entry service planning, individuals exited incarceration with a care plan covering physical, mental, and social health. An HHH case manager met clients at release and escorted them to the clinic to initiate services. This program physically broke down barriers to support, creating a direct, collaborative care pathway that enhanced integration and reduced recidivism. Evaluation data showed a 50% reduction in recidivism after program participation. In addition to offering direct in-reach services, HHH will partner with community-based reentry housing programs to meet justice-involved individuals' needs, leveraging collaborative efforts to provide comprehensive healthcare with stable housing. These partnerships ensure clients have access to safe and stable housing while they work to navigate the complexities of rebuilding health and wellbeing during reintegration to the community. As the primary healthcare provider for individuals experiencing complex social challenges as a result of housing instability, HHH's care model is specifically designed to empower individuals in taking charge of their physical and mental health while developing independence and stability. Funding from the hrsa QIF-TIJ would allow HHH to build on the success of this past initiative and develop further evidence-based practices in caring for this population during transition. This collaborative, community-based approach ensures continuity of care, reduces health disparities, and promotes successful community reentry. By providing coordinated, accessible, and holistic services, HHH can significantly improve health outcomes and quality of life for justice-involved individuals, fostering a healthier and more equitable community.